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Thursday, 14 April 2016

'Inappropriate' A&E attendance: One out of four ain't bad

Guest post by Dr Simon Howard, Associate Lecturer in Public Health, Northumbria University

Last week on the blog, Emma Dorée wrote about a statement from South Tees NHS Foundation Trust urging people not to attend Accident and Emergency departments for stomach aches caused by excessive consumption of Easter Eggs. Emma explained that one in four A&E attendances is considered inappropriate, and highlighted the NHS Choose Well campaign which helps people to select the right place to take their symptoms.

This made me wonder… is one in four A&E attendances being ‘inappropriate’ really so bad?

Clearly, the NHS is stretched at the moment, and nowhere more so than A&E, where only 83% of patients are seen and sent on their way within four hours, as compared with a target of 95%. It is natural for us to want to see performance improve, and waiting times are doubtless inflated by ‘inappropriate’ attendees.

Of course, we should wonder what is meant by ‘inappropriate’ in this context. There are many possible classifications. Of course, attending A&E seeking treatment for a sick dog is undoubtedly inappropriate. But is it inappropriate to attend for ‘hangover help’? What if the symptoms of your hangover are difficult to distinguish from the symptoms of meningitis? The final diagnosis and healthcare provider’s perspective is not necessarily the best viewpoint from which to determine ‘appropriateness’.

Even if we assume that one in four attendances truly is inappropriate, it’s reasonable to question whether that is so bad. Considering the problem in terms of sensitivity and specificity, it is vastly preferable that the self-triaging process is sensitive (i.e. all people who really need A&E attend A&E), even if that’s at the expense of a degree of specificity (i.e. some of the people who don’t need A&E still attend A&E). As a doctor, I want everyone who has a life-threatening emergency to attend A&E, not for one or two to go to their local pharmacy, and I’m willing to accept that making that happen might mean that some less urgent cases also slip through the net.

People presenting to services inappropriately is anything but a new problem. Writing in The Lancet in 1849, Joseph Hodgson - the founder of what is now known as the Birmingham Midland Eye Centre - complained of the “growing evil” of “the indiscriminate admission of out-patients to charitable institutions”. His problem was, perhaps, a little different: people referring themselves to charitable hospitals even though “one half of the patients can afford to pay the surgeon his fee”. In order to avoid detection, many of his patients chose to “dress shabbily, and even borrow their servants’ bonnets and shawls”.

To my mind, the root of the modern problem is that we expect people, most of whom rarely use the health service, to self-triage between six (or more) levels of care. This is not sensible. Campaigns admonishing people for making obviously incorrect choices don't help this core problem, and may even counteract campaigns like Be Clear on Cancer, which encourage people to consult health services with symptoms which they may not recognise as ‘red flags’.

One solution to this problem is to introduce professional triage. Back in 1849, Hodgson suggested that “each applicant be compelled to bring a note of recommendations from the clergyman”; perhaps not quite such a useful recommendation for the 21st century. NHS Direct, and its successor NHS 111, were perhaps intended to provide the modern equivalent of the clergyman’s note, but do not enjoy a high degree of public or professional confidence. This is probably because triage over the phone is very difficult, even if it has been shown in research to reduce A&E demand. Perhaps options such as embedding GPs within A&E, as proposed by South Tees CCG, will provide an answer.

For now, here’s the bottom line: even as someone working in the system, I couldn't tell you where I'm supposed to take myself if I develop an unclear symptom. Telling me how inappropriate other people’s attendances are don’t help signpost me to the right place if I have, for example, sudden hearing loss or eye pain. Like very many other people, in situations of uncertainty, I am likely to err on the side of accessing a higher level of care, as I would not want to delay urgent treatment. Though I probably wouldn’t turn up wearing my servant’s bonnet.

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